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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197492985
Report Date: 09/23/2025
Date Signed: 09/23/2025 11:15:55 AM

Document Has Been Signed on 09/23/2025 11:15 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:HERNANDEZ FAMILY CHILD CAREFACILITY NUMBER:
197492985
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, DOLORESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 793-6987
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 1DATE:
09/23/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:11 AM
MET WITH:Dolores Hernandez, Licensee TIME VISIT/
INSPECTION COMPLETED:
11:23 AM
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On 09/23/2025, Licensing Program Analyst (LPA) Justeene Tamayo met with Licensee Dolores Hernandez. A tour of the facility was provided for the One Year Required inspection. This is a two story, 3 bedroom, 3 bathroom home with kitchen/dining, living room, play room area, laundry room and garage. There is no longer an above ground pool on the premises. No bodies of water observed on the premises. Upon arrival LPA observed 1 preschool child in care, along with licensee. Licensee currently does not have any infants in care but does understand the requirements. Family members residing in the home include 3 adults (licensee, licensee's spouse, and licensee's adult son) and 1 minor child (Updated LIC279B Current Children in Home received). Facility operation are Monday-Sunday for less than 24 hours a day. Incidental Medical Services (IMS) policy was discussed.

Physical Plant: Main care is provided in the living room and playroom(toddlers) area near the backyard. Children use the bathroom in hallway on the right. Children have access to the living room and dining room area. Off limit areas include all bedrooms, bathrooms #2 and #3 (upstairs), laundry room (garage), and garage(key locked). The home was inspected inside and out for safety, clean and orderly, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds (under kitchen sink with magnet lock), medicines (kitchen drawer with magnet lock) and hazardous items (sharp knives in kitchen drawer with magnet lock) that can pose a danger to children. LPA did not observe a fireplace in the home. Safe and age appropriate toys, play equipment and materials were observed. The smoke detector and carbon monoxide detector, Fire Extinguisher (2A10BC) are in operable condition. Per Licensee no one smokes in the home. Electrical outlets are inaccessible. LPA reminded licensee, no baby bouncers saucer chairs, or any recalled and or prohibited toys or sleep/ play equipment are allowed. There is a designated area for ill children as necessary near front entrance. Per Licensee there are no weapon/firearms in the home. The facility sketch is complete and current, there is working telephone (cell).
NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Justeene Tamayo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 197492985
VISIT DATE: 09/23/2025
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Fire/Disaster Drill is complete and maintained current. Last Fire/Disaster Drill was completed on 06/20/2025

Roster complete and maintained current.

Bathroom: Shower/tub are free of hazards (child care bathroom). LPA did not observe any hazardous items in the children's bathroom. Toilet and faucet are clean and operable.

Kitchen: Sharp utensils, open bottles or alcohol are inaccessible. If food is brought from the children’s home, the container shall be labeled with the child’s name and properly stored or refrigerated. The home has a clean and fully stocked refrigerator/freezer. Licensee currently has a food program. Breakfast, lunch, snacks and dinner are provided. Naps are provided on cots in the living room.

Outdoor: The backyard is safe for children. The backyard is completely fenced (white fencing). Per licensee, she discarded the above ground swimming pool. No bodies of water observed on the premise during today's inspection. No hazardous items observed. There is another wrought iron gate on the side of the home for the one dog on the premises, as well as two barbecue pits fully covered. LPA observed sufficient play equipment and toys for outdoor activities. Per licensee, there is one dog, and two cats on the premises. Per licensee, she is in the process of adding another addition to the home that will be permitted and will be utilized for child care. LPA advised for licensee to send UIR to PRO when added addition is completed so that LPA Tamayo can conduct additional inspection before children can utilize added space.

Advisory/Other: First Aid kit was observed with supplies readily available. CPR/First Aid expires 01/09/2026. Mandated Reporter expires 03/12/2026. There are no window cords accessible to children.
NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Justeene Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 197492985
VISIT DATE: 09/23/2025
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Documents Provided and or Discussed: Fire Drill Log, Roster, Postings, Safe Sleep PIN 20-24-CCP, Individual Sleeping Plan (LIC9227), and Safe Sleep Log. Licensee stated currently does not have child care insurance.

Licensee Hernandez was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee Hernandez and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

No deficiencies have been cited at this time.

A notice of site visit was given to licensee and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee Dolores Hernandez, along with her appeal rights and Notice of Site Visit.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Justeene Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025
LIC809 (FAS) - (06/04)
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